Latin America needs to optimize health care practices for the benefit of patients and the systems themselves. A new study seeks to identify cancer care practices or technologies of low or no value that could be subject to “de-implementation” in the region.[1]
The recommendations of what “should not be done” were developed by the Latin American and Caribbean Society of Medical Oncology (SLACOM) following the concept of Choosing Wisely (how to choose wisely), an initiative promoted by the American Board of Internal Medicine (ABIM) and the ABIM Foundation to discourage unnecessary medical treatments and procedures.
A group of 21 experts from eight countries (Argentina, Brazil, Colombia, Chile, Honduras, Mexico, Peru and Paraguay) relied on a variety of documents, as well as recommendations made by other initiatives from different countries selected through a modified Delphi method that allows access to expert opinion through a series of questionnaires to achieve consensus.
To arrive at these ten recommendations, the group carried out a rigorous selection process related to prevention, diagnosis, treatment and rehabilitation practices in patients with different stages of cancer and discussed 74 unsuccessful suggestions that included the use of ineffective interventions or low-value practices, for example, due to not having a clear and possible path after obtaining the result.
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Do not use cancer-directed therapy in patients with clinical stage 3 or 4 solid tumors; there is no benefit from prior interventions and the patient is not eligible for inclusion in clinical trials. Prioritize palliative treatment to relieve symptoms.
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Do not start cancer treatment without defining the extent of the disease (staging) and discussing the intention of the therapy with the patient.
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Do not perform tests for tumor markers except to evaluate or monitor active disease.
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Do not perform positron emission tomography (PET) or computed tomography (CT) for cancer screening in healthy individuals.
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Do not perform routine colonoscopic surveillance annually in patients after colon cancer surgery. Frequency should be based on prior colonoscopy findings and guidelines.
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Do not use PET/CT to monitor patients undergoing palliative cancer treatment. Do not use routinely to detect possible disease recurrence in patients who have completed cancer treatment, unless suspected clinically or by imaging.
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In the absence of mutations EGFR In non-small cell lung cancer, the use of tyrosine kinase inhibitors is not recommended.
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Do not treat low-risk localized prostate cancer (e.g., Gleason score) with active surveillance as part of the decision-making process.
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Avoid biomarker testing and imaging for recurrent cancer in asymptomatic patients previously treated, unless there is evidence that early detection of recurrence may improve survival or quality of life, including avoiding biomarkers or imaging in asymptomatic patients treated for breast cancer with curative intent.
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Do not routinely perform adjuvant whole-brain radiotherapy when the patient has undergone stereotactic radiotherapy.
Dr. Eduardo Cazap, co-author of this work and founding president of the Latin American and Caribbean Society of Medical Oncology, said that these are recommendations for public policies or for health systems to be applied by health professionals within medical criteria.
Dr. Eduardo Cazap
“Medicine historically has been guided by what needs to be done,” Dr. Cazap said, noting that physicians are taught to come to some sort of unified assessment of what to do with a person in a given circumstance and that clinical guidelines are the next evolution of “what needs to be done,” but that they are not always used or applied.
“Other approaches have recently emerged, such as ‘how to choose wisely’, which considers not only what the guidelines say, but what is really necessary and improves the quality of care.” Such approaches constitute quaternary prevention aimed at avoiding unnecessary things or the damage that the health system produces when implementing medical decisions on healthy or sick people, the clinician stressed.
The specialist also suggested caution when taking these wise choices as medical advice, remembering that the individual patient is one thing and the policy or health system is another. As an example, he mentioned that a new technology may be of low value for daily use in the clinic, but that does not mean that it is not useful for an individual patient.
The agreement or disagreement in the recommendations is also linked to the particularities of each country, as highlighted by Dr. Robinson Rodríguez, president of the Honorary Commission for the Fight against Cancer and director of the National Cancer Institute (INCA) of Uruguay, who did not participate in the consensus, but indicated that he shares many ideas with this group.
Dr. Robinson Rodriguez
“There are many studies, whether screening or diagnostic, as well as treatments that are unnecessary and should not be done,” said Dr. Rodriguez, adding that in several aspects Latin American countries are not equal, such as the incidence of each type of cancer, which is not the same in different regions.
He also highlighted that international organizations make general recommendations, sometimes due to the difficulty a certain country has in controlling various diseases or because there are no serious registries. Uruguay has a reference cancer registry, in fact, it collaborates with the International Agency for Research on Cancer (IARC) to advise other registries and train human resources in the region, which allows it to have population knowledge of the incidence and mortality of cancer in the country and consequently, adapt the rules to its reality.
Dr. Rodriguez used mammography as an example for breast cancer screening. “The World Health Organization (WHO) recommends mammography starting at age 50, but in Uruguay we see that 20% of breast cancer cases occur in women under 50, of which 90% are between 40 and 49 years old. Therefore, the Ministry of Public Health of Uruguay recommends having an annual mammogram between 40 and 49 years old and then between 50 and 69, as well as having one every two years and even up to 74 years old. This is based on the evidence that the country has.”
Another limitation of the general recommendations is due to the necessary review and updating of the concepts. The authors of the consensus point out that 93% of the recommendations are based on evidence that has not been updated since 2018. “In three to five years it should be repeated, since 50% of the concepts can be revised,” added Dr. Cazap.
Relevant concepts
Dr. Cazap said some recommendations on what not to do are “rock solid,” as is the case with No. 1. “Between 30% and 50% of cancer spending, depending on the country, occurs in the last three months of life. Patients who are no longer curable, who will receive the rarest and most sophisticated treatments, have the highest probability of not benefiting and of being harmed because they may not get the palliative care they deserve.”
“Markers are not preventive, except in very specific contexts,” said Dr. Cazap regarding point 3, so an oncologist does not have to order tumor markers in an asymptomatic person. “In that case, we could have a fight with the prostate-specific antigen.”
“Many times a CT scan is requested unnecessarily and to request one you must have a diagnostic suspicion,” he said when commenting on point 4.
He also admitted as an exception that in the United States low-intensity CT scans are performed for lung cancer prevention in healthy people, “but they are individuals at high risk of lung cancer.”
Doing more does not mean doing better
Dr. Cazap commented that stopping overuse is sometimes a matter of avoiding “wasting money.” He mentions as an example the unnecessary expense of measuring the epidermal growth factor if the expensive drug cannot be used later. On other occasions, the goal is to harm people as little as possible.
“Following these tips is difficult. It is much easier not to follow them,” said the specialist, emphasizing that doing too much or doing unnecessarily does not mean doing better.
The problem must be addressed by society as a whole. “When people are healthy, this does not worry them. When a person or a family member is ill, the vision is extremely biased, even for someone with experience. This vision includes the phrase: ‘We must do everything we can.'” The best vision would be one that considers the cost-benefit, not only economically, but also in terms of aggression towards the patient, since each additional study can be a torture, said the doctor.
Dr. Rodriguez said that because of the number of palliative care units and the early introduction of palliative care, Uruguay has fewer problems with overuse at the end of life compared to other countries, adding that it is not waited until the last moment, as was seen before, a situation that led to causing more damage, and that now the idea is to include the participation of palliative care unit specialists early, without prejudice to specific oncological treatment. “This way, not only does it help to better alleviate symptoms, but it also helps to avoid excesses.”
Dr. Rodriguez referred to the participation of patients in decisions. “It is important, but sometimes they think that doing more things will be better and that is not necessarily the case.”
To avoid these excesses, Dr. Cazap made a recommendation to his colleagues: “Talk to the patient. If you talk, perhaps many things would not be asked. And ask. You know that patients talk little in the office and the professionals in charge do not ask, they write and then say: ‘Do this.'”
The project was supported by a grant from Bristol Myers Squibb (BMS). The authors of the consensus paper and Drs Cazap and Robinson have disclosed no relevant financial relationships.
